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                                         Sleep diagnostic category

Sleep disorders only come in two diagnostic categories, one related to sleep apnea and the other related to the failure to stay awake due to stress.

The statement that sleep disorders only come in two diagnostic categories may be misleading. According to Wilson & Nutt (2013), individuals with sleep disorders are divided by the presentation of their symptoms into three major categories: insomnias, parasomnias, and hypersomnias. Wilson & Nutt (2013) illustrate the difference between the symptom-led classification of the three-sleep disordered categories, which includes a description of insomnia as poor quality of sleep or not enough sleep. Conversely, hypersomnia is recognized as excessive sleep during the daytime, and parasomnia is identified as an unusual event or happening during the nighttime hours (Wilson & Nutt, 2013). While Holder & Narula (2022) identify obstructive sleep apnea, failure to stay awake or excessive daytime sleepiness would fall into the hypersomnia category. Both are considered common conditions related to sleep disorders (Holder & Narula,2022). Other common sleep conditions include restless leg syndrome, which would fall into the insomnia category due to its interference with sleep and its effect on one’s ability to fall asleep (Holder & Narula, 2022). Common parasomnias include nightmares, sleepwalking, and sleep-related eating disorders due to their disruption in one’s sleep cycle (Holder & Narula, 2022). 

 

Over the counter versus Prescription drug

 

The use of over-the-counter sleep aids should be encouraged over prescription drugs because OTC aids are safer and not habit forming.

Both prescribed and over-the-counter medications carry side effects. It is not always true that over-the-counter sleep medications are deemed safer and non-habit-forming over certain prescription medications. Therefore, providers should educate their patients about sleep and the potential benefits versus risks associated with using sleep aids that are prescribed or over the counter (Silva et al., 2021). I feel that safety and effectiveness can vary according to the individual. For example, some individuals with chronic insomnia may present with higher reports of anxiety and depression, and stress and show a more likely vulnerability to substance use (Silva et al., 2021). Therefore, a clinician may want to avoid controlled sleep medications that potentiate an opportunity to become habit-forming, like Ambien, Benzodiazepines (BZD), and to a lesser extent, “Z” drugs.

Furthermore, although BZDs, have empirical evidence that they treat chronic insomnia with short-term use, this medication is widely known to have associations with cognitive impairments in memory, concentration, attention, and learning (Silva et al., 2021). Conversely, over-the-counter medications used for sleep may be considered slightly safer when used as directed. However, considering the broader use of antihistamines purchased over the counter for sleep, they are known to cause sedating side effects in addition to dizziness, dry mouth, and impaired coordination. Additionally, the American Academy of Sleep Medicine does not back the off-label use of antihistamines for sleep due to a lack of evidence associated with its effectiveness and concerns for safety (Silva et al., 2021). A clinician should consider the underlying causes of the problems related to sleep, as some patients are best served with non-medical interventions that include education on sleep hygiene practices or meditation as appropriate treatment options.

 

                                                               Menopause 

 

Menopause can adversely impact sleep and lead to insomnia. According to Lee et al. (2019), menopausal women may experience disordered sleep due to ovarian hormone changes, vasomotor symptoms, restless leg syndrome, sleep apnea, and periodic leg movement syndrome. During menopause, the level of estrogen is known to decline. Estrogen is a crucial hormone that decreases sleep latency, the number of times an individual awakens after falling asleep, and their cyclic spontaneous arousals (Lee et al., 2019). Hence, a decrease in estrogen is directly correlated to reduced total sleep time (Lee et al., 2019).

Furthermore, estrogen regulates body temperature and keeps the core body temperature low while asleep (Lee et al., 2019). A decrease in estrogen changes one’s central body temperature and can lead to insomnia symptoms or poor sleep quality (Lee et al., 2019). Another interesting finding is that women can gain weight post-menopause, leading to an increased neck circumference and body mass index (Lee et al., 2019). These factors can change the anatomical upper airway and cause problems, including obstructive sleep apnea (Lee et al., 2019).

 

                                                     Use of Benzodiazepam

 

As a backup to over-the-counter sleep aids, benzodiazepines are the most useful.

Benzodiazepines are prescription medications that can treat chronic insomnia with short-term use (Silva et al., 2021). However, according to DeKosky & Williamson (2020), benzodiazepines are not recommended as a backup medication to over-the-counter sleep aids for many reasons. First, benzodiazepines are often overused and over-prescribed and are associated with adverse events, including addiction, due to their potential for dependence and abuse (DeKosky & Williamson, 2020). Second, benzodiazepines can cause side effects, including postural unsteadiness, impairment of alertness, and falls resulting in fractures (DeKosky & Williamson, 2020). These side effects are typically more pronounced in older adults due to other traumatic injuries with their use as sleep aids (DeKosky & Williamson, 2020). Long-term use of benzodiazepines can cause dementia-like symptoms and have the potential for loss of functional independence in some individuals (DeKosky & Williamson, 2020). Lastly, they can adversely interact with other medications (DeKosky & Williamson, 2020). As future clinicians, we ought to consider avoiding benzodiazepines to aid in improved sleep outcomes for our patients. Instead, a non-medical approach with lifestyle changes that include reducing caffeine, avoiding alcohol, and improving sleep hygiene can go a long way to help our patients establish a regular sleep schedule.

 

What is the best practice for insomnia assessment?

 

The best practice for assessing insomnia includes thoroughly evaluating a person’s sleep patterns, associated symptoms, and medical and psychiatric history. According to Krystal et al. (2019), a best practice insomnia assessment should include a comprehensive sleep history of an individual’s chief complaint, current sleep history, and sleep-wake cycle. A clinician should also assess a patient’s bedtime routine and nocturnal behavior and determine if they have daytime dysfunction (Krystal et al., 2019). There may be a link between psychiatric and physical conditions and insomnia (Krystal et al., 2019). Therefore, obtaining a medical and psychiatric history with a complete physical and psychiatric evaluation is necessary, including differential diagnoses and screenings (Krystal et al., 2019). This should also include reconciling a patient’s medication list, as many medications can adversely impact sleep (Krystal et al., 2019). Screening for sleep disorders, including restless leg syndrome and obstructive sleep apnea, is crucial. Evaluation of lifestyle and social factors that include work, physical activity, stress levels, and diet can also impact sleep (Krystal et al., 2019). Therefore, a clinician may assess these factors and educate the patient on appropriate modifications to improve their sleep. Finally, asking that a patient keep a sleep diary may provide a broader picture of the issues contributing to disordered sleep and should be part of the best practice assessment (Krystal et al., 2019).

 

References:

DeKosky, S., & Williamson, J. (2020). The long and the short of benzodiazepines and sleep medications: Short-term benefits, long-term harms?. Neurotherapeutics 17, 153–155. https://doi.org/10.1007/s13311-019-00827-z

Holder, S., & Narula, N. S. (2022). Common sleep disorders in adults: Diagnosis and management. American family physician105(4), 397–405.

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry: official journal of the World Psychiatric Association (WPA)18(3), 337–352. https://doi.org/10.1002/wps.20674

Lee, J., Han, Y., Cho, H. H., & Kim, M. R. (2019). Sleep disorders and menopause. Journal of menopausal medicine25(2), 83–87. https://doi.org/10.6118/jmm.19192

Silva, J., Vieira, P., Gomes, A. A., Roth, T., de Azevedo, M. H. P., & Marques, D. R. (2021). Sleep difficulties and use of prescription and non-prescription sleep aids in Portuguese higher education students. Sleep Epidemiology, 1, 100012. 10.1016/j.sleepe.2021.100012

Wilson, S., & Nutt, D. (2013). Sleep disorders: (2nd ed.). Oxford University Press.

 

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